NCLEX-RN
NCLEX Practice Test RN Questions
Extract:
Question 1 of 5
A client with a history of a deep vein thrombosis is receiving Warfarin (Coumadin). The nurse should teach the client to avoid:
Correct Answer: A
Rationale: Green leafy vegetables are high in vitamin K, which antagonizes warfarin’s anticoagulant effect. Dairy, citrus, and high-fat foods do not significantly affect warfarin.
Question 2 of 5
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
Question 3 of 5
A client with a history of a stroke is being taught to use a cane. The nurse should teach the client to:
Correct Answer: C
Rationale: The cane should be used on the weak side to support the affected leg, improving balance and gait post-stroke. Holding it in the strong hand or advancing with the strong leg is incorrect.
Question 4 of 5
A client with Pneumocystis jiroveci pneumonia is receiving intravenous Pentam (pentamidine). While administering the medication, the nurse should give priority to checking the client's:
Correct Answer: B
Rationale: Pentamidine can cause hypotension, especially during IV administration, requiring close blood pressure monitoring. Reflexes, urine output, and turgor are less immediate concerns.
Question 5 of 5
A 42-year-old client with bipolar disorder has been hospitalized on the inpatient psychiatric unit. She is dancing around, talking incessantly, and singing. Much of the time the client is anorexic and eats very little from her tray before she is up and about again. The nurse's intervention would be to:
Correct Answer: D
Rationale: The manic client's mood may easily change from euphoric to irritable. The nurse should avoid confrontation and let the client know what she can do, rather than what she cannot. Although helpful to refocus or redirect the manic client to discuss only one topic at a time, distractibility is very high and it's best to avoid long discussions. Manic clients have a tendency to manipulate persons in their environment. Staff should monitor intake, including at mealtime and snacks, and be consistent in their approach to meeting nutritional needs. Manic clients may not sit and eat complete meals, but they can carry foods and liquids from regular meals with them. Staff can monitor and give high-caloric and high-energy snacks and liquids.